MICS CABG. Putting the future of MICS in your hands today

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1 MICS CABG Putting the future of MICS in your hands today

2 This presentation is based on a compilation of the surgical techniques and protocols of: Dr. Joseph McGinn - Staten Island, New York Dr. Marc Ruel - Ottawa, Canada Dr. Steven Hoff - Nashville, TN

3 Coronary Heart Disease CHD is the leading cause of death in the United States for both men and women CAD (Coronary Artery Disease) is the most common type of heart disease Lifestyle changes, drug therapy, and/or medical procedures can effectively prevent or treat CAD in most people Most patients are first managed with drug therapy if that doesn t work What is the next step? Source - American Heart Association Heart Disease and Stroke Statistics Update

4 CABG Surgery: Standard of Care Clearly, invasive cardiac surgery is not a first-line treatment for patients where less invasive options, such as angioplasty and stenting, are feasible. Nevertheless, for many patients with advanced or diffuse disease, surgery remains the best option. While the advent of DES has cannibalized certain segments of the revascularization caseload, current research suggests that chronic total occlusions, patients with left main disease, diabetics and those with diffuse multi-vessel disease are best served by surgical intervention. 1 CABG surgery is the standard of care, and when the left internal mammary artery (LIMA) is grafted to the left anterior descending artery (LAD), patency rates are higher than 95% at 10 years, setting an extremely high benchmark for stenting to match. 2 1 Hannan EL, Wu C, Walford G, Culliford AT, et al. Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med. Jan ; 358(4): Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med. Jan , 314(1):1-6.

5 CABG or Stents for Multi-vessel Disease? New England Journal of Medicine shared the following conclusion: For patients with multivessel disease, CABG continues to be associated with lower mortality rates than does treatment with drug-eluting stents and is also associated with lower rates of death or myocardial infarction and repeat revascularization.

6 Convergence of Technology and Specialties Utilizing multiple technologies to decide what is right for the patient What is the best outcome for the patient? How do the cardiovascular specialties get there together? Disease management and patient management not procedure oriented It does not matter to the patient which specialty treats them they just want the best treatment Getting all the specialists on the same page to deliver the right care to the patient

7 Hybrid Operating Room Definition: A melding of the cardiac cath lab and cardiac surgery operating room Potential: Allows select patients to undergo intravascular interventions and cardiac surgery simultaneously to treat coronary artery disease, minimize recovery time and postoperative pain Hospital-Physician Drivers Attract top surgeons and staff Increase procedural volumes Provide efficiencies that generate revenue Allows expanded use of technology, fosters advances in techniques and enables expansion of coronary artery disease treatment

8 Hybrid Operating Room Therapies: Suitable for treating a wide variety of conditions Diseases of the coronary artery, valve, congenital heart, thoracic aorta Heart failure/cardiac rhythm disturbances Considerations: Suitable Specialties and technologies converge Multiple technologies can be leveraged to determine what is right for the patient. What is the best outcome for the patient? How do the cardiovascular specialties get there together? Patient management and disease management come first, not the procedure. Specialists need to be on the same page to deliver the right care to the patient.

9 Efficacy Technology Improvement Overall MICS Technologies Trends Goal MICS: Technique Improvement Sternotomy Surgery Invasiveness

10 Incision Size (cm) MICS CABG Evolution 25 20cm cm 2-4cm +ports 0 Sternotomy OR time Training challenge Start up and ongoing costs MICS CABG Robotic

11 I ve Seen This All Before. Not the old Minimally Invasive Direct CABG (MIDCAB) Disadvantages of MIDCAB Poor early results in the mid-late 90 s Rib-spreading and parasternal incision is painful to patients Primarily for single vessel disease (LIMA-LAD) Less access and ability to harvest the length of the LIMA Poor target visibility and access due to medial incision 1 McGinn JT, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting: dual center experience in 450 consecutive patients. Circulation.2009; 120:S78-S84.

12 MICS CABG vs. MIDCAB

13 Patient Selection/Inclusion Criteria Coronary Anatomy Left main coronary artery disease (CAD) with normal right coronary artery (RCA) Triple vessel disease with medium to large posterior descending artery (PDA) Complex proximal left sided lesions with or without large branch involvement Previous unsuccessful stenting

14 Patient Selection/Inclusion Criteria Co-Morbidities: Includes patients who are at a high risk for problems with median sternotomy Long-term steroid use Severe chronic obstructive pulmonary disease (COPD) Advanced age Need for other major operative procedures Severe deconditioning Patients with arthritic or orthopedic problems Patients who want the procedure and seek out less invasive surgical options

15 Contraindications Contraindications Emergency cases Patients with hemodynamic instability Potential Contraindications Previous CABG surgery Morbid obesity Patients with posterolateral branch disease EF < 20% Patients with peripheral vascular disease (PVD) Patients with dilated cardiomyopathy

16 MICS CABG Overview Off-pump CABG procedure Lateral mini-thoracotomy LIMA takedown via direct vision, with video assistance, or robotically Anastomoses performed under direct vision through the thoracotomy Complete revascularization in multi-vessel disease, a pumpassisted beating heart or hybrid approach

17 Why MICS? The Patient Perspective Better cosmetic outcome No sternotomy scar Less physical restrictions 1 Shorter length of stay 1 Quicker return to normal activities 2 1 Poston RS, Tran R, Collins M, et al. Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques. Ann Surg. 2008:248: Lapierre H, Chan V, Sohmer B, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting via small thoracotomy versus off-pump: a case-matched study. Eur J Cardiothorac Surg. 2011;40:

18 MICS CABG Incisions

19 Why MICS CABG? MICS CABG is the next step: Similar grafting strategy to sternotomy CABG Enduring results (LIMA-LAD) 1 Shortened hospital stay and recovery time 2 Avoid a sternotomy and improve the cosmetic outcome Attractive alternative for patients and cardiologist 1 Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med. Jan , 314(1): Poston RS, Tran R, Collins M, et al. Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques. Ann Surg. 2008:248:

20 Why MICS? The Surgeon Perspective New skill set in a competitive market Get an edge with cardiologists in their respective markets Increase referrals from cardiologists Marketing opportunity for the practice Gain patients back with hybrid that were lost to stents Increase case load Economic benefit to the hospital Hospital Reduced length of stay 1 Can competitively market advanced cardiac procedures 1 Poston RS, Tran R, Collins M, et al. Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques. Ann Surg. 2008:248:

21 Mediastinitis = Lower Reimbursement Source - American Heart Association Heart Disease and Stroke Statistics Update

22 MICS CABG The Tools and Technology Octopus Nuvo Heart Postioner Starfish NS Tissue Stabilizer ThoraTrak MICS Retractor System

23 MICS CABG The Medtronic Total Package ThoraTrak MICS Retractor System for access to minimally invasive cardiac surgery Interchangeable blades to accommodate various cardiovascular procedures and anatomies Low-profile design Octopus Nuvo for tissue stabilization Low profile, flexible, strong, quick connect system Starfish NS for multi-vessel access - Ability to position for LAD, Diag, OM s, PDA through a thoracotomy

24 MICS CABG Pump-assisted Beating Heart Bio-Medicus Femoral Cannula Kits - Arterial and Venous All of the beating heart technology, with the addition of our worldclass cannula, for a pump-assisted approach allows for complete revascularization through a thoracotomy

25 MICS CABG Product Overview ThoraTrak MICS Retractor System Octopus Nuvo Tissue Stabilizer Starfish NS Heart Positioner

26 ThoraTrak MICS Retractor System Modular retractor system with interchangeable blades to accommodate various procedures and patient anatomies Reusable, stainless steel retractor designed specifically for minimally invasive procedures Low-profile design

27 Octopus Nuvo Tissue Stabilizer Incorporation of the Octopus Evolution headlink for minimally invasive Malleable pods Increased headlink flexibility and range of motion Flexible suction tubing Three pod design Smaller headlink for MICS CABG procedure Quick connect, detachable headlink New whale tail Improved flex arm

28 Starfish NS Heart Positioner Enables multi-vessel therapy through a thoracotomy Presents coronary artery for direct vision anastomosis Remote shaft insertion eliminates clutter at the incision site Dependable positioning technology that you are already using in your OPCAB patients No additional suction tube

29 MICS CABG Technology Overview* Starfish NS Heart Positioner through a sub-xyphoid incision Octopus Nuvo Tissue Stabilizer through the 6 th ICS Positioning and stabilization of several vessels directly under the mini-thoracotomy is possible Active pain management with pain pump UC a EN

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